Last July, researchers at UCLA reported that the brains of people diagnosed as "hypersexual" do not display distinctive responses to sexual images. The study's authors interpreted their findings as evidence that hypersexuality, defined as a harmful and distressing preoccupation with sex, is not a true addiction or mental disorder.
A week after the UCLA study was published, Ariel Castro pleaded guilty to 937 criminal charges stemming from his kidnapping of three women whom he imprisoned and repeatedly raped over the course of a decade. "I'm not a monster," he insisted at his sentencing hearing. "I'm just sick. I have an addiction, just like an alcoholic has an addiction."
Around the same time, disgraced former congressman Anthony Weiner, who resigned in 2011 after admitting he had "sexted" photos of his genitals to various women, was attempting an improbable political comeback by seeking the Democratic nomination for mayor of New York City. His campaign suffered a major setback when it emerged that Weiner, a married man, had continued conducting virtual liaisons with Internet acquaintances even after quitting Congress.
All of these stories raise the question of how we should view people who don't control their sexual urges. Are they addicted to sex in the same way that an alcoholic is bonded to booze or a junkie is hooked on heroin? If so, does that mean they are no longer responsible for their behavior? And to what extent does neuroscientific evidence such as the electroencephalograms (EEGs) used in the UCLA study illuminate these issues? The debate about the nature of hypersexuality exemplifies a broader cultural confusion about addiction, a concept that has been medicalized to the point that people think it means both less and more than it really does.
If I Only Had a Brain Scan
The UCLA study, reported in the journal Socioaffective Neuroscience and Psychology, involved 52 volunteers whose scores on tests of sexual compulsivity were similar to those of "people seeking help for hypersexual problems." The researchers, led by the neuroscientist Nicole Prause, hooked the subjects up to electroencephalographs and showed them pictures that ranged from romantic to sexually explicit. Prause and her colleagues found that the brain responses registered by the machines were related to the subjects' self-reported levels of sexual arousal but not to their hypersexuality scores. "Hypersexuality does not appear to explain brain responses to sexual images any more than just having a high libido," Prause said in a university press release.
The researchers presented their results as evidence that hypersexuality is not really an addiction. "A diagnosis of hypersexuality or sexual addiction is typically associated with people who have sexual urges that feel out of control, who engage frequently in sexual behavior, who have suffered consequences such as divorce or economic ruin as a result of their behaviors, and who have a poor ability to reduce those behaviors," the press release noted. But according to Prause and her colleagues, "such symptoms are not necessarily representative of an addiction-in fact, nonpathological, high sexual desire could also explain this cluster of problems."
For someone unblinded by neuroscience, it is hard to make sense of this explanation. Sex addiction is defined by a pattern of behavior, a pattern exhibited by the subjects in this study, who reported that their sexual preoccupations and actions were so unrestrained that these had gotten them into trouble at home or work. Are these problems less real because their EEG tests were not abnormal? If the essence of addiction is a life-disrupting attachment that continues despite undesirable consequences, why does it matter whether Prause's subjects displayed a special "P300 response"?
Prause's reliance on EEG data to cast doubt on the reality of the problems reported by her subjects is an example of what I call "neuroreductionism": the tendency to perceive human experiences as valid or genuine only when they can be linked to measurable brain activity. In their recent book Brainwashed: The Seductive Appeal of Mindless Neuroscience, Oasis Clinic psychiatrist Sally Satel and Emory University psychologist Scott Lilienfeld detail the faulty science and logic underlying this mindset.
Neuroreductionism is the latest twist on the medicalization of addiction. Medicine has come up with wave after wave of biological explanations for addiction, ranging from the belief that narcotics such as heroin have special chemical effects that cause addiction to wild claims implicating the endorphins as addictive culprits. All these theories posit that addiction is caused by the things to which people become addicted.
My view, by contrast, is that people can become addicted to anything, whether drugs, alcohol, food, shopping, gambling, love, or sex, if it is the focus of an encapsulating experience that alleviates bad feelings and buttresses their self-esteem. Contrary to the common view of addiction as a choice-nullifying disease, this approach holds people accountable for their actions. Addicts are actively involved in building their attachments and can modify their behavior when they have an incentive to do so. Alcoholics drink moderately at home with their parents, for instance, and addicted smokers wait all morning during work until they can smoke outdoors. They might prefer to indulge their addictive impulses instantly, but those impulses can be resisted and ultimately eliminated.
Likewise, many highly sexual people do not act on their urges in ways that create problems. Even among those who qualify for the "hypersexual" label, the vast majority do not kidnap women and rape them. Since sex addicts clearly can conform to social expectations, legal limits, and moral principles, it is right to punish those who, like Ariel Castro, egregiously fail to do so.
Anthony Weiner's transgressions were trivial in comparison with Castro's. But his evident lack of self-control still prompted debate about exactly what his problem was.
"The candidate's behavior meets a fundamental criterion for addiction: his exhibitionist acts continued despite negative consequences," Time's health writer Maia Szalavitz claimed. "It's hard to imagine a better example of compulsive repetition: although he lost his job and put his marriage, family and entire political future at risk, the former Congressman nonetheless engaged again in the exact type of online behavior that brought him to public humiliation."
Yet Szalavitz was not ready to call Weiner an addict. "It's still not clear whether sexual compulsions qualify as an addiction," she said. "The [UCLA study] argued that they don't, because hypersexual people process sexual cues just like normal people do-and differently from the way addicts respond to drug cues. But the question is far from resolved. And whatever you want to call the issue, Weiner still has a problem, since compulsions can be just as disruptive as addictions, and equally difficult to overcome."
Szalavitz is at odds with herself. She says Weiner-who displayed the defining characteristic of addiction, persistence in destructive behavior-may not have been truly addicted because scientists found that sex addicts don't have special brain responses to sexual stimuli. Instead, Weiner may suffer from a destructive sexual compulsion. But that is a distinction without a difference. Szalavitz, who is as well-informed on addiction and drugs as anyone who has ever written for a mainstream news outlet, still gets tripped up by neuroreductionism. According to this way of thinking, if a person behaves like an addict but doesn't produce the right brain scan, he has to be called something else.
Before Cocaine Was Addictive
Although addiction historically referred to just about any strong attachment or hard-to-break habit, physicians began using the term to describe a medical syndrome at the turn of the 20th century. They had in mind addiction to drugs. Specifically, they had in mind addiction to opiates, since they erroneously believed that only opiates caused tolerance (a need for larger doses to achieve the same effect) and "physical dependence" (withdrawal symptoms). Alcohol and barbiturates were added to the list later, but physicians and pharmacologists continued to describe other drugs as merely "habituating." The U.S. surgeon general's landmark 1964 report on the health hazards of smoking, for instance, deemed nicotine habituating but not addictive. The same distinction was applied to cocaine, amphetamines, marijuana, and various other drugs.
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